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Physician Resource Applications

About Resource Applications

Remote Access - Allows access to hospital intranet, email and web-enabled clinical applications while outside the hospital. You must have internet access for remote access to MemorialCare network.

Sign Up for Resource Applications

As a benefit of being a Physician Society Member, you can sign up for resource applications. Please complete the form below. If you are not a Physician Society Member, please apply for membership.

(*indicates a required field)

First Name *

MI

Last Name *

Medical Specialty *

Affiliations *

Long Beach Medical Center

Miller Children's and Women's Hospital Long Beach

Community Medical Center Long Beach

Orange Coast Medical Center

Saddleback Medical Center

MemorialCare Medical Group

Greater Newport Physicians

Check all that apply

GNP Report Center Access

Request access to GNP Report Center

Practice Name *

Practice Address *

Please select a Country to show address fields.

Country *

Address 1 *

Address 2

City *

State *

ZIP code *

Phone *

Fax

Enter none if you do not have a fax number

Email Address *

Office Manager’s Name *

Office Manager’s Phone *

Resource Applications

Location of Use *

Where you will be using the resource applications

Your Computer & Hardware *

Resource Applications You Are Requesting *

MemorialCare Email Account

Remote Access

Check all that apply

Other Non-Physician Society Member Resource Applications:

Comments

Resource Applications Agreement

In connection with your professional relationship (Employee, Workforce Member, or Physician) with Memorial Health Services (“MemorialCare”), MemorialCare is granting you permission to access certain of its systems (the “Systems”) remotely. This permission is subject to your strict adherence to the restrictions and limitations described below. The ability to access the Systems remotely is a privilege, not a right, which may be modified or revoked by MemorialCare at any time, without cause or notice.

Workplace Safety. You are responsible for regularly checking your remote workspace to ensure it complies with all health and safety requirements, including appropriate workstation configuration for reduction of repetitive stress and other similar injuries. MemorialCare does not control and has no responsibility or liability for ensuring the health and safety of the location from which you remotely access the Systems.

Use of Remote Access Technology. You must perform your work using only a computer provided by MemorialCare or a personal computer that meets the technical requirement defined in Appendix A. All remote access must be made using only those procedures specified by MemorialCare and only for the purposes specifically authorized by MemorialCare. You are responsible for ensuring only MemorialCare authorized personnel (e.g., no family members, office staff) will have access to (i) MemorialCare provided computers, (ii) confidential and proprietary information, or (iii) MemorialCare system access procedures. In the event you become aware of any unauthorized access to the Systems or MemorialCare’s data or confidential information, you must immediately notify the MemorialCare Service Desk at 562-933-9450. You may not sell or otherwise dispose of any computer, laptop, or other equipment provided by MemorialCare. You must at all times ensure that access to the equipment is limited as described in this provision. In particular, you may not leave unattended a computer remotely connected to the Systems (e.g., go to lunch with your computer logged into our systems). You may not copy MemorialCare confidential or proprietary information to any form of Removable Media (defined below). In the event MemorialCare confidential or proprietary information is reduced to printed form (e.g., by a printer or fax), all copies of such printouts must be returned to MemorialCare. Papers containing MemorialCare confidential or proprietary information that are no longer needed may not be disposed of at your remote work location. All such papers must be returned to MemorialCare for proper destruction.

Work Site Inspections. On reasonable notice, you agree to permit MemorialCare to inspect the location and computers from which you access the Systems remotely.

Compliance with all Applicable Policies. Although you may be authorized to work at a remote work location, you will still be obligated to comply with all applicable MemorialCare policies and procedures, including those relating to information security, confidentiality, privacy, and use of information technology.

Supporting and Defining Policy. At all times your actions and use of MemorialCare computing resources must be consistent with MemorialCare policy, specifically, “Policy Regarding Responsible use of Technology Resources and Information.” A copy is attached to this participation agreement.

I certify that my identification number and password represent my signature and as such, carry all the ethical and legal implications of a written signature. I will not disclose my electronic signature password to any person or permit another person to use it. I further agree to use electronic signature for all my dictated reports.

I understand that in selecting "Yes" to this permission form I am acknowledging I have read, understand, and agree to be bound by the restrictions and limitations described above.

I certify that the information provided above is true and correct. I agree that MemorialCare, its representatives, and any individuals or entities providing information to MemorialCare in good faith shall not be liable to, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this document. I hereby give permission to release to this MemorialCare information about my medical practice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the content of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorneys listed in this form to discuss any information regarding this case with MemorialCare.

I agree *

YES

For additional information about the MemorialCare Physician Society or for questions about this form, please call 866-405-EPIC (3742).